Permit Change Request Form - NPDES/SDS Permit Program

/ Permit Change Request Form
NPDES/SDS Permit Program
Doc Type: Permit Application

The National Pollutant Discharge Elimination System (NPDES)/State Disposal System (SDS) Permit Program regulates wastewater discharges to land and surface waters. This form applies to municipal and industrial NPDES/SDS permitted facilities that are requesting a name change, transfer of ownership, or permit termination.

Complete the form by typing or printing in black ink. Attach additional sheets as necessary. For more information, please contact the Minnesota Pollution Control Agency (MPCA) at: In Metro Area: 651-296-6300 or Outside Metro Area: 800-657-3864.

Permittee Information

Permittee name: / Permit number: / MN
Mailing address:
City: / State: / Zip:
Telephone: / Fax: / E-mail:
Authorized agent: / Title:

Facility Information

Facility name:
Street address:
City/Township: / State: / Zip:
County:

Name Change Permit Transfer Permit Termination

(Check which of the above this application is for and proceed to the applicable section below.)

Name Change

Complete this section only if the Permittee name or Facility name is changing. If there is a change in ownership, complete “Permit Transfer Section”.

Permittee name:
Facility name:
Permittee mailing address (if different from above):
City: / State: / Zip:
Telephone: / Fax: / E-mail:
Authorized agent: / Title:

Permit Transfer

Facility has been sold to or is being leased by a new: Owner Operator Public Entity

Permittee

Permittee name:
Facility name:
Permittee mailing address:
City: / State: / Zip:
Telephone: / Fax: / E-mail:
Authorized agent: / Title:

Main Contact (Operator/Plant Manager)

Name: / Title:
Mailing address:
City: / State: / Zip:
Telephone: / Fax: / E-mail:
24-Hour emergency contact backup name: / Telephone:

Discharge Monitoring Report Contact

Name: / Title:
Mailing address:
City: / State: / Zip:
Telephone: / Fax: / E-mail:

Billing Contact

Name: / Title:
Mailing address:
City: / State: / Zip:
Telephone: / Fax: / E-mail:

Engineer or Consultant

Name: / Title:
Mailing address:
City: / State: / Zip:
Telephone: / Fax: / E-mail:

Permit Termination

Discharge termination / Facility closed
Discharge routed to sanitary sewer / Other
Briefly describe reason for termination request:

Signatures

Federal regulations (Section 309(c)(2) of the Clean Water Act and State regulations (Minn. R. 7001.0070) require the authorized signer to be one of the following:

For corporation, a principal executive officer of at least the level of vice president
For a partnership or sole proprietorship, a general partner or the proprietor, respectively
For a municipality, state, federal, or other public facility, either a principal executive officer or ranking executive official
If the operator of the facility is different than the owner, both the operator and the owner according to items A to C.

“I understand that the submittal of this Request for termination does not release me from liability for any violations of this permit or the Clean Water Act”.

“I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person, or persons, who manage the system, or those persons directly responsible for gathering the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment”.

Printed name: / Title:
Current or previous owner
Authorized signature: / Date:

Permit Transfer

Printed name: / Title:
New owner
Authorized signature: / Date:

Applications that are submitted without an authorized signaturewill be returned. Please make a copy for your records.
Send the completed form to:

Water Quality Document Coordinator

Minnesota Pollution Control Agency

520 Lafayette Road North

St. Paul, MN 55155-4194

651-282-5332 or 800-657-3864•Available in alternative formats

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